Other Questions

The Deputy who tabled Question No. 6 apologises that he is doing a radio programme. The Deputy who tabled Question No. 7 is not present in the Chamber.

Questions Nos. 6 and 7 replied to with Written Answers.

Hospital Waiting Lists

Billy Kelleher

Question:

8. Deputy Billy Kelleher asked the Minister for Health when the upward trend in hospital waiting lists is expected to be halted; and if he will make a statement on the matter. [20781/15]

We have discussed this issue on many occasions. It has been raised with the Minister at the health committee at which it has been suggested it be dealt with by the National Treatment Purchase Fund, some other assistance from elsewhere or the provision of additional resources to the public system. Something has to be done. The pretence we are getting on top of waiting lists needs to stop. People are now waiting alarming lengths of time to see a consultant on an outpatient basis.

Reducing long waiting times for hospital treatment is a key priority for the Government. To comply with the commitment which I announced in late January of a maximum permissible waiting time of 18 months by the end of June and 15 months by year end, the Health Service Executive, HSE, has put in place specific measures to address waiting lists more efficiently in collaboration with acute hospitals, the special delivery unit and the National Treatment Purchase Fund.

The effect of these measures is already evident. In early February, a total of 4,995 patients required treatment to achieve that measure. As of Friday, 22 May, this number had reduced to 2,693.

The HSE, in conjunction with hospital groups, is focused on delivering on this requirement through maximising the use of internal capacity within and across hospital groups in the first instance. However, there are key limiting factors, primarily in terms of theatre nursing staff and consultant manpower in particular specialties. Consequently, it is recognised that judicious outsourcing is also required and this is being managed through a public tendering process.

The elimination of the longest waiting periods for treatment is a key performance objective for 2015. Its achievement will allow for progressive improvement in access to treatments throughout the year.

I want to bring the Minister’s attention to the statistics for several regions. In Waterford, for example, 27,156 people are waiting for an outpatient appointment, of whom 11,127 have been waiting 12 months or longer. That is up almost 2,000 people since January 2015 and up 8,935 in a year. That is the way the trend is going. While there may be dips from time to time, the overall trend is in one direction and it is an alarming problem.

In Cork, the figures reveal 52,000 are on outpatient waiting lists at Cork University Hospital, the Mercy and South Infirmary Victoria. Almost 13,000 people are waiting longer than 12 months for an outpatient appointment. This is not for an inpatient appointment but someone’s first contact with a consultant. It is quite alarming.

Whether the Minister has to admit defeat or otherwise, I do not mind how he does it. However, he has to do something to ensure that these people can access treatments and additional capacity is provided. If it requires using the private sector, so be it. Something must be done and quickly.

It is important to understand the figures. The higher figure will always be high. It is anyone who is waiting for an outpatient appointment for any period. That includes people who are waiting two weeks or two days. As health services expand, more consultants are appointed and more clinics are established, that number will always be high. That is the way it works.

What we do need to address is people waiting too long. The figures the Deputy used are for people waiting for over a year which is a patient safety risk. Anyone who is currently waiting over a year will have their appointment by the end of the year. We will use whatever additional finance is necessary to do that. Unfortunately, in a number of sub-specialties, the relevant specialists just do not exist. We will either have to offer people appointments abroad or, in some cases, may not be able to offer them an appointment as I would so wish. It will not be financial constraint, however, that prevents that from happening.

There is a bigger picture too. Waiting lists need to be better managed. Significant numbers of people do not turn up for the appointments for which they have been waiting ages. Significant numbers of people on waiting lists are not really on them at all as they already have been seen by a different consultant or may have subsequently gone private. We also have a problem with referral rates. The numbers referred is increasing more than it should be. Often people wait for a long time to see a consultant, only to be told that they did not need to see the consultant at all or need to see a different consultant. We need to improve the quality of referrals from general practice into secondary care. The e-referral programme is a big part of that.

We have been talking about these particular issues for a long period and the overall challenges facing services. The Minister spoke about referrals. At the same time, general practitioners, GPs, are unnecessarily referring more people to the acute hospital system and to consultants due to lack of resourcing in primary care. GPs are effectively looking at the number of people outside their surgery doors. The Minister is one himself, so he should know how it works. Any condition that is complex or needs further analysis will often be referred on because the GP does not have the time, resources or systems and is under pressure. That is one reason there are more people going on to the waiting lists.

There is no point in us pretending but there has been a massive increase in the number of people waiting over a year. In Cork, it is almost a 600% increase. I accept the more consultants and lists one has, the bigger the headline figure will be. The one underneath that, namely people waiting a year, does not lie. That is simply because there is no capacity in the system.

It is a combination of factors. There are inappropriate referrals. Ask any speech and language therapist, any physiotherapist or any consultant and they will tell one about inappropriate referrals, namely people who should not have been sent to them in the first place. This happens, unfortunately, and needs to be better addressed. I hope the e-referral system over the next several years will allow us to tackle this well.

The Deputy is correct that there are issues in general practice. People have been referred to consultants and hospitals for 24-hour holter monitoring or minor surgical procedures, all of which could be done in general practice if it were properly funded and GPs were remunerated accordingly. That is one of the items that is now in discussion as part of the new general medical services, GMS, contract, namely better remuneration for GPs and encouraging them to do 24-hour monitoring, suturing and other minor procedures. The minor surgery pilot is already funded for this year to cover some of these.

There is a mix of issues involved. However as I said earlier, anyone who is waiting a year or more for an outpatient appointment should have that by the end of the year with the exception of a few small specialties where the specialists do not exist.

Mental Health Services Provision

Mick Wallace

Question:

9. Deputy Mick Wallace asked the Minister for Health his plans to establish an acute mental health unit in Wexford General Hospital in view of the fact that the need for same has been long recognised; and if he will make a statement on the matter. [20549/15]

I accept putting patients in acute mental health beds is not ideal or seen as best practice. When A Vision for Change, a good document, was published in 2006, it looked away from locking up people behind walls and drugging them to their eyeballs. The plan, however, was that the acute bed units would not be done away with until there was enough support and facilities in the community to replace them. This has not really happened and A Vision for Change has remained just that, a vision.

The HSE Waterford-Wexford mental health service serves a population of nearly 280,000. The executive is continuing its approach to develop integrated mental health care across both counties.

The significant funding provided by this Government is enabling Waterford-Wexford mental health services to implement the recommendations of A Vision for Change, to move from a traditional hospital-based model to a more patient-centred and community-based care.

In 2010, the acute mental health unit in St. Senan's Hospital, Enniscorthy, County Wexford was amalgamated with Waterford mental health services to provide a 44-bed acute inpatient mental health unit in University Hospital, Waterford. In addition, arrangements are in place whereby service users who live in north Wexford, and who attend Tara House mental health services in Gorey and require acute inpatient admission, have access to Newcastle Hospital, County Wicklow. Overall, 49 acute inpatient beds are available in the area which meets the requirements set out in A Vision for Change. Development of community mental health services include day hospitals and associated services at Wexford, New Ross, Enniscorthy and Gorey.

In addition, mental health services covering Wexford include Tara House in Gorey, Carn House in Enniscorthy, Summerhill in Wexford, Maryville in New Ross and a suicide crisis assessment nurse service available in Wexford. The latter provides a skilled mental health nursing service for those in suicidal or self-harm situations. This is based at the emergency department in Wexford General Hospital where there is a liaison nurse-led, seven-day service. In July 2014, a new purpose built crisis respite unit opened in Enniscorthy, providing ten respite beds for service users referred through a community mental health team, for respite care.

The Deputy will be aware that the Health Service Executive has statutory responsibility for the planning and delivery of services at local level, and that any new service or capital development proposals can only be considered and prioritised in the context of the annual HSE national service plan, and the multi-annual health capital budget. I understand that the HSE has already supplied the Deputy with a more detailed response on 28 April 2015 to his recent parliamentary question on this matter.

There are day hospital services in Wexford, as the Minister of State has listed, but they are closed after 5 o'clock in the evening. To gain access to those services people need a referral letter from their general practitioner. What is a family supposed to do if a family member is in acute crisis and suicidal? The person has to go to an accident and emergency department and sit in a corridor or on a trolley waiting to be accessed. As there is no consultant psychiatrist in Wexford General Hospital, the psychiatric liaison nurse will have to ring Waterford hospital to consult a psychiatrist there. If it is decided that the person in crisis needs to go to an acute bed in Waterford, they are sent off and will have to go through the accident and emergency department in that hospital also. Therefore, a Wexford patient will have to go through two accident and emergency departments. It has happened in the past that people sent to Waterford hospital from Wexford General Hospital were sent home, having travelling all the way there while in acute distress. It is all a bit mad. It is not a good service.

Back in 2009, Susan Lynch, the HSE manager of mental health and elderly services, said that an acute ward in Wexford General Hospital was more than a proposal, that it was in the HSE's south capital plan, but it never happened. It fell off the lorry. Why did it not happen?

I am responsible for many things but I am not responsible for what happened back in 2009.

I did not say that the Minister of State was responsible.

I do not know what happened to that proposal. I speak not only to HSE people but to the people who deliver the service on the ground and I speak to one person in particular in Wexford on a regular basis. An investment of more than €18 million has been made in Wexford. A Vision for Change was published in 2006 and I believe it needs to be updated, but I have to say that if I listened to every request for an acute hospital I would reopen every psychiatric hospital in the country. On the other hand, I have a magnificent new unit in Cork in which people will not work, which is illogical in regard to psychiatric services. Wexford is well served with day hospitals, as the Deputy rightly said. There is a respite unit, crisis houses and an assessment nurse which many other places do not have. Also the ECD who runs the service in Waterford is an incredible man. When I ask him questions such as the one the Deputy has asked, and I will inquire about it with him, he tells me there has never been a case where somebody needed to be admitted who was not admitted. There may be instances where people need to be assessed and returned to their own community and I have no doubt that happens. I will make further inquiries on foot of the Deputy's parliamentary question.

People have died because they were not admitted to hospital; people have committed suicide in Wexford. The Minister of State has said that Wexford and Waterford are well served, but, according to the HSE's mental health division plan for 2015, spending per capita in the mental health area in the region is €148. That compares to €223 in Carlow-Kilkenny, €198 in south Tipperary and €206 in Mayo. The average number of acute beds per thousand of population across the country is 0.21 and it is 0.16 in Waterford-Wexford. People in Wexford who have to go through two accident and emergency departments are at a disadvantage to people in Waterford who only have to go through one accident and emergency department. Also, people in Wexford have to travel to Waterford and Wexford is one of the poorest served areas. This area has a suicide rate of double the national average and an unemployment rate as of today of more than 23%. That is incredible.

Could the Deputy put his question, as his time is up?

It has one of the highest levels of teenage pregnancy and one of the highest levels of illiteracy. The service is not good enough. I am serious about this.

I am only responsible for the mental health end of it, as the Deputy will know, I am not responsible for the other pieces.

That is the knock-on effect.

When I got this job I had the same view as the Deputy in regard to how people in crisis access the services. I was of the opinion that a person should not go through an accident and emergency department but because of the difficulties in regard to self-harm and possible self-harming, the accident and emergency department is the appropriate place, and I am convinced of that now, but the service would also include the suicide assessment nurse-led team. People who have a difficulty with their mental health and are in crisis would be assessed both for their mental health and for their physical well-being. I will make further inquiries on foot of the Deputy's parliamentary question. I am setting up a new group to examine what is beyond A Vision for Change and if it reports back to me with a recommendation that we should have an acute unit in every single town, I will take a serious look at that but as of now I am not convinced of that.

Patient Safety Agency Establishment

Billy Kelleher

Question:

10. Deputy Billy Kelleher asked the Minister for Health the reason the programme for Government commitment to establish a patient safety authority has not been honoured; and if he will make a statement on the matter. [20782/15]

I wish to ask the Minister for Health the reason the programme for Government commitment to establish a patient safety authority has not been honoured and if he will make a statement on the matter. In view of the HIQA report into the infant deaths in Portlaoise hospital and its recommendations and the testimony given to us at the Oireachtas Joint Committee on Health and Children in recent weeks, there is an urgent need for us to address that failed commitment and ensure we have a patient safety authority of standing.

I am strongly of the view that any new patient advocacy service should be set up independent of the HSE from the outset. For this reason I removed reference to the establishment of an interim patient advocacy agency from the service plan for 2015.

My view has been supported by the recent recommendation made in the HIQA investigation report on services at Portlaoise hospital on the need to establish an independent patient advocacy service. The HIQA recommendation is that an independent patient advocacy service should be in place by May 2016. I fully agree with the recommendation and intend to see it implemented well in advance of the timeline provided by HIQA.

The scope, role and functions of the independent advocacy service will be considered along with the appropriate structural, governance and funding arrangements that need to be put in place. My Department will be consulting widely on the best way to get the service up and running in the shortest possible timeframe.

The role of the independent patient advocacy service will be to support and advocate for patients in their dealings with the health service. Regrettably, the health service has not been as responsive to patients who have had bad experiences as is required. I believe the patient advocacy service can assist in redressing the balance in the relationship between patients and service providers.

The proposed establishment of a number of new statutory bodies is something that I have given consideration to in the context of the immediate priorities associated with the overall health reform programme. I believe there are some functions associated with the patient safety agency that are currently carried out to an independent high standard already by HIQA. I do not propose at this stage to interfere with these arrangements and instead intend to address the major gap in advocacy and support to patients through the new independent service.

I also intend to improve the advice available to me on patient safety through the enhancement of my own Department's patient safety function under the leadership of the chief medical officer.

This will allow such advice to be incorporated within the existing accountability arrangements between the Minister for Health and the HSE, HIQA and other regulators and health bodies.

It is welcome that the Minister will establish an independent advocacy agency. The best way we can address the issue of advocacy for patients and those who use the heath service is to try to ensure we have accountability. The best form of accountability is to have information available to the public, including on the performance of hospitals and individuals within hospitals in terms of outcomes, assessments and comparators across health services, in order that people can scrutinise hospitals and see how good their performance is. While HIQA is very much into the quality side, there is a gap evolving in the information flow in ensuring full information and accountability across the health service. The patient safety authority should have a role in ensuring people are aware of the performance of hospitals in order that they can make informed choices.

The Deputy makes a very valid point. Information that is available, provided it is collected accurately, should be made public in order that patients can see it and if there are discrepancies between hospitals and services, they can at least ask probing questions as to why. That is why a few months ago, for the first time, my Department published data by hospital for all sorts of issues, including caesarean section rates in maternity services and in-hospital mortality rates for heart attacks and strokes. This was replicated at community level. We intend to expand the report next year and include more information in it, including perinatal mortality statistics. Information on certain complications is already included. It will be produced by my Department and published annually. It is very important that we include patient experience data. An external survey will be conducted of patients' experiences of hospitals and it will be reported on. A satisfaction survey was conducted in the past and will be carried out again and will be published annually.

While the Deputy does not do this, others abuse the statistics. Medical statistics are produced within competence intervals and have a margin of error, plus or minus 5% or even 25%, particularly when dealing with low numbers. We all need to stand together against vested interests and some in the media who turn data into league tables that are not statistically significant. We need to be united against that misinformation and sensationalism.

"Lies, damned lies and statistics" comes to mind.

We do the statistics.

Others do the damned lies.

The damned lies would not be done over here either. Some days ago I referred to the perinatal pathology services in the context of the debate on Portlaoise hospital. It is critically important that people have confidence in the statistics and that the statistics cannot be massaged and manipulated for various, sometimes nefarious, reasons such as when it is tried to suggest there is a deficiency in a service when it is just a statistical blip due to small numbers. I understand all of this.

On the issue of MRSA in hospitals and trying to get hospitals to be cleaner, only when the information was being published did hospitals across the service become motivated and concentrate on making an effort to encourage staff, clinicians and management to work together to address it. When information is available, people can make informed decisions on whether a hospital is run well and whether the clinical outcomes are correct. It should be part and parcel of the agency if HIQA is unable or incapable of doing it.

I agree in principle and if HIQA wants to start publishing hospital by hospital data for MRSA, it is free to do so and there will be no objection from me. However, it is important that the data are reliable. Unreliable data are no good to anybody and can be harmful. The role of the patient advocacy service will be to advocate for patients generally and individually. I do not intend it to gather and publish statistics, which can best be done by the patient safety unit in my Department or HIQA. We do not need to duplicate another agency to collect and publish statistics. We should just do it. It does not require a statutory agency to do something that can already be done. The patient advocacy service will do something that is done by NGOs but is not resourced and supported to the extent it should be.

Health Services Reports

Caoimhghín Ó Caoláin

Question:

11. Deputy Caoimhghín Ó Caoláin asked the Minister for Health the position on the second investigation into the tragic loss of baby Jamie Flynn and other cases of concern, including the loss of another newborn baby on 12 May at or following birth at the maternity unit at Cavan General Hospital; if he will provide details of the persons who have been engaged to carry out each of the investigations in train; when he expects to receive each of the reports commissioned; if he will commit to publish each report on receipt; and if he will make a statement on the matter. [20776/15]

I seek an update on the four investigations into or reviews established of the loss of newborn babies at Cavan General Hospital in the past 13 months. Who carried them out? Has the Minister intervened, or will he intervene, to ensure those entrusted with the work will give sufficiently of their time to allow for the earliest possible conclusion of their investigations or inquiries and present their findings and recommendations for the earliest possible implementation, I hope contributing to a safer service and the restoration of public confidence?

I thank the Deputy for the question. I am conscious of the personal tragedies of the families at the centre of these sad incidents and do not want to intrude on their privacy. I offer my sincerest sympathy to the families involved who have suffered such a sad loss. As Minister for Health, I do not have access to any patient's medical records, report or medical information which is confidential and should not be discussed on the floor of the House, even if I had access to it. The HSE incident management policy is being followed and reviews of the circumstances of the cases are being undertaken.

Regarding the incident which occurred in November 2012 and referred to by the Deputy, the first clinical incident review was undertaken and completed in July 2014. However, a second clinical review was commissioned in September 2014 following a legal challenge which saw the first review quashed. A draft report from the second review team is due shortly. A second review of a case which occurred in April 2014 is also under way and a draft report is being finalised. A review of a third infant death in Cavan General Hospital in May 2014 is also under way. A fourth infant death occurred earlier this month and the process of establishing a review team in line with HSE's national incident management policy is under way and should happen forthwith. There should be no further delay.

Pending the outcome of the reviews of the incidents referred to and in view of the need to respect the privacy of the families concerned, I am not in a position to make available any further information on the investigations at this time. I have been assured that HIQA will conduct a focused programme of monitoring of compliance with the National Standards for Safer Better Healthcare across maternity services nationally. This programme will include the maternity unit at Cavan General Hospital. HIQA has commenced this work which will be completed by the end of the year.

Separately, the HSE is taking steps to commence a quality, risk and patient safety assurance review to assess the current governance arrangements in place in selected HSE-run maternity units. Cavan General Hospital and South Tipperary General Hospital are to be included in this review. If immediate patient safety concerns are identified during this review I expect them to be acted on immediately.

I join the Minister in extending my continuing sympathy to the families of the tragic babies at Cavan General Hospital. Although I do not know who has been given responsibility for the 2014 reviews, I know the four names of those entrusted with the second investigation review of the tragic loss of baby Jamie Flynn. The information has been publicised. Will the Minister tell us who is conducting the further reviews of the May tragedies and if the offer of responsibility has issued in the most recent tragic loss? I can comment on the list of those who have been asked to investigate a second time the tragic death of baby Jamie Flynn. They are eminent practitioners and professionals. My concern is the length of time it takes. They are very busy people in their respective areas of responsibility and, as a result, the time they can invest in carrying out these investigations may be limited.

Is the Minister is considering making future appointments to such positions on as near to a full-time basis as possible to ensure the speediest possible reporting, publication of findings and implementation of recommendations?

Each review team comprises a chairperson and three other members. I have the names but I am not sure whether it is appropriate to divulge the names of individuals who are participating in confidential reviews.

Will the Minister furnish them to me separately?

I will have to get advice on whether it is appropriate to share the names.

The Minister should consult as he pleases.

I cannot understand why there would be a different opinion. One is against another.

If the Minister for Justice and Equality were asked to divulge the names of jury members currently hearing a trial, I do not think that would be appropriate.

No, it would not. There is no analogy.

Without consulting on the matter I would prefer not to provide the names of individuals participating in a review. I hope the Deputy understands why. In regard to the fourth case, the review team has not yet been established. We have been in contact with the hospital to impress on it the importance of beginning that review expeditiously.

I agree with the Deputy that individual case reviews in Cavan, Portlaoise and elsewhere are taking far too long. If we assign people to work on them on a full-time basis, that would mean moving them from front-line activities. Perhaps that is something we need to do or alternatively we should use people who have retired from clinical practice. There are consequences for other patients when people are reassigned from their front-line activities to carry out reviews.

It merits consideration, whether in terms of people who are retired or in other circumstances. We need an expeditious review and a report at the earliest opportunity so that we can act on the recommendations. That is crucial for re-establishing public confidence. It is in the interest not only of the families who have been bereaved and the wider catchment of the maternity unit in Cavan General Hospital but also of those who are first class in their roles within that hospital and who feel their abilities are being questioned by virtue of the fact these tragedies have occurred without actions or conclusions necessarily being undertaken. It is important for all concerned that the review is completed expeditiously. I again ask the Minister to ensure that will be the practice in the future.

I agree with the Deputy that it is important individual case reviews are carried out expeditiously, provided they are also done properly and thoroughly. Sometimes that can take time but the fact that they can continue for several months and, in some cases, more than a year is difficult for the patients and families concerned. They want to find out what happened and to be assured it will not happen to somebody else. That should be doable in weeks or months rather than taking six months or a year. The Deputy is correct that it casts a shadow of doubt over the clinicians who looked after the patients. That can cause stress for the clinicians even though it is found in the vast majority of cases that they did the best they could in the circumstances. The issue also arises in respect of Portlaoise. I will put in place measures to assist those involved to complete the case reviews much more quickly.

Apologies were received from Deputy Broughan who is not here to put Question No. 13. The Deputies who submitted Question No. 12 and Questions Nos. 14 to 18, inclusive, are not present.

Questions Nos. 12 to 18, inclusive, replied to with Written Answers.

Symphysiotomy Payment Scheme

Clare Daly

Question:

19. Deputy Clare Daly asked the Minister for Health if he is satisfied that the payment scheme to which survivors of symphysiotomy may apply is being administered consistently and constitutes an effective remedy; and if he will make a statement on the matter. [20564/15]

As we have limited time, if Deputy Clare Daly does not introduce her question we might be able to take an initial reply and a supplementary question.

Will I be allowed to ask a supplementary question?

The surgical symphysiotomy payment scheme commenced on 10 November 2014. It was originally estimated that 350 women would apply to the scheme but 576 applications were accepted. Applications are being assessed by the former High Court justice Maureen Harding Clark. The scheme has in the region of €34 million available and participants will receive awards at three levels, namely, €50,000, €100,000 and €150,000. The scheme was designed to be simple, straightforward and non-adversarial, and it aims to minimise the stress for the women concerned. It was designed following meetings with all three support groups, two of which have welcomed its establishment. It was established to give women who do not wish to pursue their cases through the courts an alternative simple and non-adversarial option in which payments are made to women who have had a surgical symphysiotomy irrespective of whether negligence is proven.

Ms Justice Harding Clark has informed my officials that 206 offers have been made to women as of 22 May 2015, including one offer that was rejected. Some 194 of those offers had been accepted and 11 offers are awaiting a response. Of the 194 offers accepted by applicants, 118 were assessed at €50,000, 71 at €100,000 and five at €150,000. A large number of applications have been made without medical records or evidence of symphysiotomy and this information is being sought by Ms Justice Harding Clark in order to progress the applications. Where there was a delay arising in the compilation of a woman's supporting documentation due to difficulty in obtaining medical records, applications were accepted by the scheme provided the application was received within the time period set out in the scheme with a written explanation of the reasons for the absence of the documentation.

The scheme is voluntary and women do not waive their rights to take their cases to court as a precondition to participating in it. Women may opt out of the scheme at any stage in the process up to the time of accepting their award. It is only on accepting the offer of an award that a woman must agree to discontinue her legal proceedings against any party arising out of a symphysiotomy or pubiotomy. Deputy Daly may be aware of a High Court judgment delivered on 1 May 2015, where the judge dismissed the claim for damages by a 74 year old woman who had a symphysiotomy 12 days before the birth of her baby in the Coombe Hospital in 1963. The judge ruled that even though the woman has suffered since the operation, the practice of prophylactic symphysiotomy “was not a practice without justification” in 1963. The judge also stated in his judgment that "Though I would in the words of Sir Ranulph Crewe, Chief Justice of England, 'take hold of a twig or twine-thread' to uphold the plaintiff’s case, I must find that this remarkable lady whose story indeed deserves to be told must fail in her case against the defendants".

While the Government is aware of the comments made by the UN Human Rights Committee, it believes that the provision of the ex gratia scheme, together with the ongoing provision of support services by the HSE, including medical cards, represents a fair and appropriate response to this issue.

I understand the UN Human Rights Committee will express its disagreement with the Minister at its next hearing. It is not acceptable that elderly women who were butchered in their youth, who lost connections with their children and relationships with their husbands, and who continue to live in pain are being forced to participate in this scheme. As the Minister pointed out, the overwhelming majority of these women were offered a paltry payment of €50,000. That is one third of the amount the judge administrating the scheme will be paid in a year. The five people who got the maximum payment because of a lifetime of agony are still getting less than what the judge is paid in one year. That exposes the severe limitations to the scheme. I am aware of the recent court case but the criticisms made by the UN committee about the fact that people were being exonerated and that nobody took responsibility will be taken further. The Minister will have to revisit the matter on human rights grounds because his response is not good enough.

The UN committee is free to offer its opinion on any matter it considers relevant but in this country we are ruled by our laws and justice is administered by the courts. We are an independent sovereign State. It is up to the women individually to decide whether to apply for the scheme and to accept the award. The vast majority have accepted their awards. They do not have to prove negligence in any case. With the exception of symphiosotomy on the way out, those who have gone to court were not able to prove that the practice was not without justification at the time it was done.

Written Answers follow Adjournment.